Tag Archive for: nursing

PATIENT SAFETY

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WEEK2/Discussion Question 2

RESEARCH WORKFORCE ISSUES AND PATIENT SAFETY. SELECT ONE OF THE SUGGESTED REFERENCES LISTED BELOW.

Suggested References:

Ko, E., Nelson-Becker, H., Park, Y., & Shin, M. (2013). End-of-Life decision making in older Korean adults: Concerns, preferences, and expectations.Educational Gerontology, 39(2), 71–81.

Roulston, A., Bickerstaff, D., Haynes, T., Rutherford, L., & Jones, L. (2012).  A pilot study to evaluate an outpatient service for people with advanced lung cancer. International Journal of Palliative Nursing, 18(5),225–233.

Sandvik, A., Melender, H., Jonsén, E., Jönsson, G., Salmu, M., & Hilli, Y. (2012). Nursing students’ experiences of the first clinical education: ANordic quantitative study. Nordic Journal of Nursing Research & Clinical Studies /Vård I Norden, 32(3), 20–25.

Shisana, O., Rice, K., Zungu, N., & Zuma, K. (2010). Gender and poverty in South Africa in the era of HIV/AIDS: A quantitative study. Journal of
Women’s Health (15409996), 19(1), 39–46.

Based on your research, select an article and complete the following tasks:

· Identify and describe the research problems, purpose, objectives, and hypothesis of the research.

· Evaluate the credibility and validity of the study.

APA format references needed.

Case Scenario

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The case scenario provided will be used to answer the discussion questions that follow.

 

Case Scenario

 

Mr. C., a 32-year-old single man, is seeking information at the outpatient center regarding possible bariatric surgery for his obesity. He reports that he has always been heavy, even as a small child, but he has gained about 100 pounds in the last 2–3 years. Previous medical evaluations have not indicated any metabolic diseases, but he says he has sleep apnea and high blood pressure, which he tries to control with sodium restriction. He current works at a catalog telephone center.

 

Objective Data

 

1.     Height: 68 inches; Weight 134.5 kg

 

2.     BP: 172/96, HR 88, RR 26

 

3.     Fasting Blood Glucose: 146/mg/dL

 

4.     Total Cholesterol: 250mg/dL

 

5.     Triglycerides: 312 mg/dL

 

6.     HDL: 30 mg/dL

 

Critical Thinking Questions

 

What health Risks Associated with Obesity does Mr. C. have?

 

Is Bariatric Surgery an appropriate intervention? Why or Why not?

 

Mr. C. has been diagnosed with Peptic Ulcer Disease and the following medications have been ordered:

 

1.     Magnesium hydroxide/aluminum hydroxide (Mylanta) 15 mL PO 1 hour before bedtime and 3 hours after mealtime and at bedtime.

 

2.     Ranitidine (Zantac) 300 mg PO at bedtime.

 

3.     Sucralfate/Carafate 1 g or 10ml suspension (500mg / 5mL) 1 hour before meals and at bedtime.

 

The patient reports eating meals at 7 a.m., noon, and 6 p.m., and a bedtime snack at 10 p.m.

 

Plan an Administration Schedule that will be Most Therapeutic and Acceptable to the patient.

 

1.     Assess each of Mr. C.’s Functional Health Patterns using the information given. (Hint: Functional Health Patterns include health-perception – health management, nutritional – metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception – self-concept, role-relationship, sexuality – reproductive, coping – stress tolerance.)

 

2.     What Actual or Potential Problems can you Identify? Describe at Least Five Problems and Provide the Rationale for Each.

 

 

health policy topics

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Assignment Details

Health Policy Briefs provide succinct overviews of health policy topics. The intended audience is policymakers, journalists, and others concerned about improving health care in the United States. The briefs explore arguments made on various sides of a policy proposal. They provide guidance on available research behind each perspective. Health policy briefs are created by experts in the field through funding from public and private grants.

Select one policy brief from the Robert Wood Johnson Foundation website https://www.rwjf.org/en/library/collections/health-affairs-briefs.html

In your role as an advanced practice nurse, how would you advocate for or against the policy implementation?

In your paper you may take the position either for or against the policy proposal, or both.

Page length: 3-4 pages exclusive of cover page and references.

Support your paper with a minimum of three scholarly references.

To view the Grading Rubric for this Assignment, please visit the Grading Rubrics section of the Course Resources.

Assignment Requirements:

Before finalizing your work, you should:

  • be sure to read the Assignment description carefully (as displayed above);
  • consult the Grading Rubric (under the Course Resources) to make sure you have included everything necessary;
  • utilize spelling and grammar check to minimize errors; and
  • review APA formatting and citation information found in the Writing Center, online, or elsewhere in the course.

Your writing Assignment should:

  • follow the conventions of Standard English (correct grammar, punctuation, etc.)
  • be well ordered, logical, and unified, as well as original and insightful;
  • display superior content, organization, style, and mechanics; and
  • use APA 6th edition formatting and citation style.

PLEASE FOLLOW THE ASSIGNMENT RUBRIC AND MAKE SURE ALL REQUIREMENT DONE COMPLETELY AND CLEAR. AVOID USING NON_ACADEMIC WORD> PROOF READING THE ASSIGNMENT

Down syndrome. 

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Note: Word Document, APA Style.

 Exercise One:

Mrs. V, a healthy 45-year-old woman, gives birth to a child. There are no outward complications associated with the birth but, when examined by the pediatrician, the child exhibits abnormal facies, a single palmar crease, hypotonic muscles, and loose pelvic joints. Following chromosomal analysis, a diagnosis of Down syndrome is made.

Discussion Questions (Provide answers based on evidence and reference your responses using APA format)

1. Discuss the cause of Down syndrome.

2. What risks factors exist in the family history? Why are these thought to be risk factors?

3. Discuss further characteristics that the child may show as he gets older.

Exercise two:

Charlie is a 3-year-old in a community preschool. The staff reports that he tends to put everything in his mouth and is frequently found eating dirt. A home visit by a school staff member to discuss the problems with his parents reveals a generally clean environment in a very old home that was being renovated. Recently, Charlie has been falling behind in academic skills compared with the other children in his class; his linear growth has slowed, and he is tired and irritable. His physician noted pallor and what look like “pencil lines” on the gums adjacent to his teeth. He ordered blood tests, which revealed a low hemoglobin level and an elevated lead level.

Discussion Questions (Provide answers based on evidence and reference your responses using APA format)

1. Based on the patient history, signs and symptoms, and lab test results, discuss the probable environmental factors responsible for Charlie’s ingestion of lead.

2. Discuss the other toxic effects of lead poisoning that Charlie might experience if the situation is not addressed.

3. Discuss other possible sources in children’s environments that have been identified as containing lead.

obesity

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Case Study 1:

Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following:

  • Atenolol 12.5 mg daily
  • Doxazosin 8 mg daily
  • Hydralazine 10 mg qid
  • Sertraline 25 mg daily
  • Simvastatin 80 mg daily
Case Study 2:

Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following:

  • Warfarin 5 mg daily MWF and 2.5 mg daily T, TH, Sat, Sun
  • Aspirin 81 mg daily
  • Metformin 1000 mg po bid
  • Glyburide 10 mg bid
  • Atenolol 100 mg po daily
  • Motrin 200 mg 1–3 tablets every 6 hours as needed for pain
Case Study 3:

Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following:

  • Glipizide 10 mg po daily
  • HCTZ 25 mg daily
  • Atenolol 25 mg po daily
  • Hydralazine 25 mg qid
  • Simvastatin 80 mg daily
  • Verapamil 180 mg CD daily
To prepare:
  • Review this week’s media presentation on hypertension and hyperlipidemia, as well as Chapters 19 and 20 of the Arcangelo and Peterson text.
  • Select one of the three case studies, as well as one the following factors: genetics, gender, ethnicity, age, or behavior factors.
  • Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
  • Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
  • Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.

With these thoughts in mind:

By Day 3

 

Post an explanation of how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you selected. Then, describe how changes in the processes might impact the patient’s recommended drug therapy. Finally, explain how you might improve the patient’s drug therapy plan.

Bipolar Disorder

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plagiarism must be less than 15% . i need the assignment is 11 hours.

Assignment: Assessing and Treating Clients with With Bipolar Disorder

Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients often present as depressive or manic, but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder.

Learning Objectives

Students will:
  • Assess client factors and history to develop personalized plans of bipolar therapy for clients
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring bipolar therapy
  • Evaluate efficacy of treatment plans
  • Analyze ethical and legal implications related to prescribing bipolar therapy to clients across the lifespan ..

 

The Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
    •  you can use my sample/ edit or do a new assignment.

you can edit or use my sample with same medication therapy.

Walden University .. 6630n

2 Assessing and Treatment for Bipolar Disorder Patient Introduction Bipolar disorder is not an uncommon illness. It is a very chronic and severe mental disorder, affecting approximately 1-2% of the adult population. The signs and symptoms of bipolar disorder are different depending on the type of episode (i.e., manic or depressive). Each episode marks a critical change from the way a person usually acts and their typical mood, and can be characterized by a sudden change in the general attitude of the patient, the way the patient thinks and the behavior. 1 The changes will be sudden that it will be noticed by people around (Robert et al., 2017). This dangerous demonstrative unpredictability mood disorder can be found in all area of life, that is, from the poor to the rich, this disorder affects millions of people in all facets of life (Robert et al., 2017). Bipolar disorder can be seen mostly in the age starting at 25years or older, but it is not totally absent in the teenage age. It shows that about 2.6 percent of the population are diagnosed as bipolar. 3 (National Alliance on Mental Illness, 2017).

If not well treated ,Bipolar disorder can be critical; 1 early identification of symptoms with an appropriate treatment plan may include psychotherapy, medications, a healthy lifestyle and a regular schedule will keep the patient healthy (National Alliance on Mental Illness. (2017). 1 The NP should have a good understand of this disorder to be able to take care of this the patient because of its long-term management and how it affects the health in totality (National Alliance on Mental Illness. (2017). 1 My focus of this paper will look into an Asian American Woman with a bipolar disorder, symptoms management, diagnosing the symptom, and the complete treatment. The paper will consider the most safe and appropriate options of treatment and the outcome as the treatment, and care.

Decision Selected My patient is an Asian American woman age 39 years with 4 children and 3 ground children. The husband notices that sometimes she will be singing loud to the top of her voice and dancing not to the music she sang. In another time she will just fill like not doing anything and nothing will interest her, and she will lay on the bed for hours without going to the business she spent her years building and love so much.Patient is withdrawn and non-interactive. 4 She is diagnosed Bipolar disorder.

1 Decision # 1 Reason Selected My best treatment of choice for this disorder will be to begin Risperdal 2 mg orally twice a day. Risperdal is the best choice to treat bipolar disorder. (Lee et al., 2011). Risperdal called risperidone is in the chemical class benzisoxazole derivatives which are antipsychotic. It is an effective medication for bipolar disorder (Lee et al., 2011). The reasons of choosing Risperdal is because it is used to treat schizophrenia and the risperidone works with the brain to stabilize the brain (Lee et al., 2011). Risperidone rebalances dopamine and serotonin to improve thinking, mood, and behavior. Risperidone belongs to a class of drugs called atypical antipsychotics approved by U.S. Food and Drug Administration (FDA) The drug is also used to treat symptoms of bipolar disorder and irritability (NAMI, 2017).

Expected Results We will need to have some subjective and objective changes. 1Patient should be able to verbalize changes within the first month of the treatment.

During the next visit with the patient after one month, she is expected to express changes in the clarity of her brain. The freedom from indistinctness or ambiguity because of the medicine will help her to balance certain natural substances in her brain.She should also notice a change in her ability to concentrate on her activities (Lee et al., 2011). No side effects.

Differences between Expected outcome and Actual outcome Patient came back after a month (4 WEEKS) and report that she experiences some improvement in the symptom including some improvement with concentration. My patient reported some drowsiness. 1 Drowsiness is one of the side effect of high dose of Risperdal. The genetic testing, reveals that she is positive for CYP2D6. Asians are more likely to have decreased CYP2D6 activity compared to Caucasians (Lee et al., 2011). I will reduce the dosage of this medication. 1 A positive outcome should be that there was a little bit of improvement in symptoms, patient able to sleep, more concentration. Patient and family report drowsiness during the day time which is one the side effect of high dose Risperdal.

Decision Point Two Reason Selected The next best option is not to discontinue Risperdal, but to lower dose to Risperdal 1 mg orally at hours of sleep (HS) since expected outcome was not achieved based on decision one. My patient and , her family reported that patient has been drowsy during the day because of Risperdal 2mg. I will continue on Risperdal because the patient confirm improvement on the symptoms and the side effect observed was a regular adverse reaction because of her descendant background (American Psychiatric Association, 2017). The reduction to Risperdal 1mg BID to Risperdal 1 mg will be closely monitor.

Expected Results Risperdal 1mg orally at bedtime is a reduced dosage from the 2mg which is expected to eliminate the drowsiness and toxicity in the patient Stahl, (2013).The patient is expected to continue to have decrease in the bipolar symptom. The effect of the medication should be observable and notice by the family member as a testimony (American Psychiatric Association, 2017).

Differences between Expected outcome and Actual outcome During the patient four weeks follow up examination shows that the bipolar disorder symptom dissipated to noticeable level. This indicate a therapeutic effect of Risperdal 1mg at night brought about the therapeutic effect on the patient and patient is tolerating and adjusting to the medication in a positive way (Dean, 2017). The patient did not experience the drowsiness and there was no toxicity, therefore the expected result and the actual result were the same. Risperdal therapy will continue with this medication and the dosage, and a close monitoring will still be needed until the next four weeks appointment (Dean, 2017).

Decision Point Three Decision Selected Risperdal 1mg orally at HS will be continued Reason for Selection The decision to continue with the medication was because the desire result, and the actual result are in pari-passu. To change the current medication or tamper with the dosage may offset the patient and thereby destabilize the rate of her healing (Dean, 2017). The patient is still under assessment and close monitoring continue until the next appointment date.

Expected Results It is expected that the patient will increase in good mental stability and continue to maintain reduction in bipolar disorder symptom with the dosage of Risperdal 1mg at night (Robert et al., 2017). The patient is anticipated to having good sleep at night and well improve in her interaction with relatives and friends, with ability to concentrate on matters that concern her and carrier (Robert et al., 2017).

Differences between Expected outcome and Actual outcome The therapeutic decision is working in this patient in accordance to the expectation. The treatment agrees with the standard way of treatment of an Asian descendant, the starting procedural treatment for bipolar disorder to the maintaining of such patient that are been positive for CYP2D6.The side effect of drowsiness in the day and toxicity is agreement with Asian descent (Robert et al., 2017). The patient will have to be place on the same medication till the next visit for examination. The actual result is that the medication is achieving the therapeutic effect that is needed by the patient (Dean, 2017).

Ethical Considerations for Treatment plan Ethics demand that a patient should agree to treatment before it could be administering unto the patient. The law concerning patient’s preferences for treatment are overlook when the patient is in jeopardy of life threatening or severe psychiatric illness. Psychiatric advance directives are employing to make decision on the patient (Srivastava, 2011). When a practitioner treating a patient with bipolar is confronted with ethical conflicts of helping the patient to attain best result or their autonomy. The autonomy will be the choice of the practitioner (Srivastava, 2011). The law clearly stipulate that practitioners should always carefully consider what moral weight should be given to the values of doing well and avoiding harm (U.S. Food and Drug Administration, 2017).

2 Conclusion Psychiatric nurses should assess the function of the client not only during admission even during remission period and plan for rehabilitation services since functioning is a complex and demanding task. However, it is very important to bring back the client to his fullest possible level to normal life by planning effective psychoeducation about illness, communication training and teaching problem solving skills to client and family. 1 Many drugs are available for the treatment of bipolar disorder, but the professional will have to carefully select a medication that will be the best treatment for the patient. It is worth knowing that genetics influences the absorption of drugs, metabolism, excretion, and distribution. In the case study the Asian woman with positive CYP2D6 will exhibit a certain side effect which will not be in a patient with negative CYP2D6 (Dean, 2017). Therefore, the dosage and frequent of dispensing of drugs be based on the genetic testing (National Alliance on Mental Illness, 2017). The treatment of bipolar disorders in Asian descent must be handled carefully and in accordance with the Food and Drug Administration set guidelines (U.S. Food and Drug Administration, 2017). In conclusion the safety of the patient and the life of family and friends should be the paramount concern of the practitioners.

References American Psychiatric Association. (2017). 1 Treatment of Patients with Bipolar Disorder.

Retrieved from: 1http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf Dean, L. (2017). 1 Risperidone Therapy and CYP2D6 Genotype. Retrieved from:

1 https://www.ncbi.nlm.nih.gov/books/NBK425795/ Lee, S. Y., Martins, S. S., Keyes, K. M., & Lee, H. B. (2011). 1 Mental Health Service Use by Persons of Asian Ancestry With DSM-IV Mental Disorders in the United States. Psychiatric Services (Washington, D.C.), 62(10), 1180–1186.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698479/ Nami National Alliance on Mental Illness. (2017). 1 What Is Risperdal and What Does It Treat?

Retrieved from: 1 https://www.nami.org/learn-more/treatment/mental-health-medications/risperidone (Risperdal).

Robert, M., Keck, P., & David Solomon, D. (2017). 1 Bipolar disorder in adults:Choosing maintenance treatment. Retrieved from: 1https://www.uptodate.org/contents/bipolar-isorder-in-adults-choosing-maintenance-treatment Srivastava, S. (2011). Ethics Commentary: Bipolar Disorder: 1 Ethical Considerations in the Treatment of Bipolar Disorder. Retrieved from:

1 https://focus.psychiatryonline.org/doi/abs/10.1176/foc.9.4.foc461?journalCode=foc Stahl, S. M. (2013). 1 Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

U.S. 1 Food and Drug Administration. (2017). 1 The Facts on Bipolar Disorder and FDA- Approved Treatments. Retrieved from: 1https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm530107.htm

Role of Adhering to the Standard of Care

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Assignment 1:

Recognizing the Role of Adhering to the Standard of Care

When providing health care, there are standards of care which a reasonably prudent provider should follow. Providers at all levels are held to these standards of care. Failure to provide competent care to your patients will put you at risk for malpractice. Remaining current with the evidenced-based guidelines and providing optimal care will minimize the risk of liability.

For this Assignment, you will create a PowerPoint presentation that explains any legal implications that exist for failure to adhere to a standard of care, the key elements of malpractice, and compare the differences in malpractice policy options.

To prepare:

Consider the importance of using professional resources such as the National Guideline Clearinghouse to guide care delivered

Create a PowerPoint presentation no more than 15 slides in length that addresses the following:

Identify and explain any legal implications that exist for failure to adhere to a standard of care

Identify and explain the key elements of malpractice

Compare the differences in malpractice policy options

Politics, Stress, and Sleep

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This is the discussion question that is needed to be answered

Module 2: Discussion

Attached Files:
UTA CNHI Logo| Module 2: Discussion

Politics, Stress, and Sleep

question-bubble.png In your reading assignments for this module, you read about a classic example of politics and health promotion in the episode of Rick Perry and the HPV vaccine. For your original post, cite another example of politics and a health promotion topic. An example could be smoking cessation and politics (whether on the local, state, or national level). Thoroughly explain how politics and the selected health promotion topic are related. Your post should clearly demonstrate a thorough understanding of the example being provided. Remember to include an APA formatted in-text citation and corresponding reference from a recent (within last 5 years) professional journal or website (NIH, CDC, etc.).

 

Provide your initial post, then engage at least two of your online colleagues in a discussion about his/her initial posts. Therefore, you should have at least one initial post and one response to each of two colleagues. Please note that your postings and responses must be “substantive”, which means that they are to be made AFTER you have read the assigned course material and additional self-chosen material. Please note that your Discussion Board assignments are worth a significant part of your course grade, therefore, you are expected to put thought and effort into these entries.

Original post is due by Wednesday at 2359, and the two responses to peers are due by Saturday of Module 2 at 2359.

An APA formatted in-text citation and corresponding reference from a recent (within last 5 years) professional journal or website (NIH, CDC, etc.) are required in your initial discussion post. Blogs, magazines, and newspapers are NOT considered scholarly, professional sources.

depressed man

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Respond to at least two of your colleagues who were assigned to a different case than you.  Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.

If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

Case #29 The depressed man who thought he was out of options.

The patient is a 69-year-old male with unremitting chronic depression. He has suffered from depressive episodes for 40 years and has always had a good response to treatment until 5 years ago when he relapsed on venlafaxine. Two years ago, he underwent nine treatments of ECT with partial response. He has tried every known antidepressant and augmentation available in the past few years.

The patient should be asked about recent stressful life events, consumption of illicit drugs, alcohol abuse, current medical conditions and prescribed medications (Preda, 2018). If the patient was in my office, I would also want to ask questions to gain an understanding of the severity of his depression. It is important to assess the overall severity of depression symptoms because symptom severity corelates with suicide risk (Preda, 2018). The PHQ-9 screening could be used, and this screening asks about feelings of hopelessness, loss of pleasure in doing things, and feelings of being better off dead. A focused severity assessment for hopelessness, suicidal ideation, and psychotic symptoms is recommended; these symptoms independently increase the risk for suicide (Preda, 2018). This patient reports feeling severely depressed and demoralized, as well as, helplessness, hopelessness, and worthlessness. His depression is the worst it has ever been.

Family members are helpful informers, they can ensure medication compliance, and can encourage patients to change behaviors that continue depression (Halverson, 2019). Some questions I would ask family members would include whether the patient is taking their medication and I would ask the family to provide some insight as to how the patient behaves at home. The wife reports that she feels he is letting go and giving up.

There are no lab tests that will confirm depressive disorder, however, labs can be ordered to rule out illnesses that may present as depressive disorder such as endocrinological or neurological diseases. Labs tests may include TSH, B12, RPR, HIV test, electrolytes, BUN and creatinine, blood alcohol, and blood and urine toxicology screening. Neuroimaging can help clarify the nature of the neurologic illness that may produce psychiatric symptoms, but these studies are costly and may be of questionable value in patients without discrete neurologic deficits (Halverson, 2019). CT scanning or MRI of the brain should be ordered for suspected organic brain syndrome. PET scans provide a means for studying receptor binding of certain ligands and the effect a compound may have on receptors (Halverson, 2019).

Differential diagnosis would include major depressive disorder, bipolar disorder, and/or poor or rapid metabolism. From 25-50% of cases of Treatment Resistant Depression (TRD) are associated with bipolar disorder; this is by far the most common individual cause of TRD (Preda, 2018). The remaining 50-75% are associated with noncompliance, poor or rapid metabolism, or misdiagnosis (Preda, 2018). This patient is exhibiting signs and symptoms consistent with major depressive disorder, such as anhedonia, loss of energy, feelings of worthlessness, depressed mood, which have been consistent for more than a two week period. TRD is defined as MDD that fails to respond to at least two antidepressant trials that are of adequate dose and duration; the two antidepressants may belong either to the same class or to different classes (Preda, 2018).

SSRIs, which include fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine, have become the first-line treatment for major depression (Brown, 2011). SSRIs work by selectively blocking the reuptake of serotonin to increase the amount of serotonin available in synapses in the brain (Brown, 2011). The STAR*D trial examined various strategies for treatment resistant depression in patients who did not respond to an initial SSRI, including switching to another SSRI antidepressant, changing medication class, and switching to CBT. Fair quality studies have indicated a trend toward greater effectiveness when switching to an SNRI such as venlafaxine than with citalopram, fluoxetine, or paroxetine (Halverson, 2019).

For patients with major depressive disorder, I would start the patient on citalopram 20mg and increase the dose to a maximum of 40mg. If the patient failed to respond, I would change to venlafaxine 75mg daily extended release tablet and increase dose if tolerated. I could not find any contraindications or dosing alterations needed for Citalopram or venlafaxine related to ethnicity.

Week 20 follow-up concluded with ordering venlafaxine levels. This had been considered 20 weeks prior. I agree with ordering this lab and I would have opted to do this before pursuing ECT. A lab is much less invasive, less expensive, and without the side effects he is experiencing at this point.

The patient’s aphasia and mood are improving but his mood is still low. He hadn’t had labs completed. The venlafaxine stayed at 225mg and aripiprazole was increased. Aripiprazole was increased to 15mg. When used to augment treatment with an SSRI or SNRI for depression, the dose would be no greater than 10mg. I disagree with this change.

By week 28 the patient labs show low levels of venlafaxine on a 225mg dose. The dose was increased to 300mg. Up to 600mg/day has been given for heroic cases (Stahl, 2014). I agree with this change. His aripiprazole was discontinued. I agree with discontinuing since the venlafaxine was not at a therapeutic level.

The patient was still not showing improvement by week 32. Another blood level was drawn. At week 36, the level was low on a 300mg dose. The dose was increased to 375mg. The patients BP is good and there have not been any side effects. He has shown some improvement after the dose increase. An increase to 450mg was made and levels ordered. By week 40, the patient was feeling hopeful and mood was improving. His lab values were in the low therapeutic range. At 450mg/day, the patient was still within the dosage for a heroic case. He was tolerating well. The suggestion at this point was to raise dose by 75mg/day, redraw level and raise again to 600mg if still in therapeutic range. I think this is a good strategy based on the patient’s improvement and his ability to tolerate the dose. Lessons learned include the importance of therapeutic drug level monitoring when this is an option. Possible reasons for low levels could be: pharmacokinetic failure, genetic variant causing pharmacokinetic failure, or noncompliance. Finally, never give up.

 

References

Bienenfeld, David. (2018). Screening tests for depression. Medscape. Retrieved from https://emedicine.medscape.com/article/1859039-overview

Brown, Charles. (2011). Pharmacotherapy of major depressive disorder. US Pharmacist, 36(11), HS3-HS8. Retrieved from https://www.uspharmacist.com/article/pharmacotherapy-of-major-depressive-disorder

Halverson, Jerry. (2019). Depression. Medscape. Retrieved from https://emedicine.medscape.com/article/286759-overview

Howland, R. H. (2008a). Sequenced treatment alternatives to relieve depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(19), 21–24. doi:10.3928/02793695-20081001-05. Retrieved from Walden Library databases.

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medical surgical unit

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Alex is the manager of a 36 bed medical surgical unit. Administration has announced to all managers that the overall patient satisfaction scores have declined drastically during the past year. Specifically, on his unit, lights are not being answered in a timely manner, patients do not feel the nursing staff care about them, and they would not recommend this hospital to their friends.

Alex is assigned the task of bringing these scores up within a 3 month period. If you were Alex, how would you approach this challenge?

1-How would you develop an action plan?

2-How would you assure the entire staff is dedicated to making this work?

3-How would you deal with staff members that were resistant?

4-How would you measure progress during this 3 month period?

Your response should consist of complete sentences and should be at least one complete paragraph, but it should be no more than three paragraphs in length.